NOTICE: This opinion is subject to formal revision before publication
in the preliminary print of the United States Reports. Readers are requested
to notify the Reporter of Decisions, Supreme Court of the United States,
Washington, D.C. 20543, of any typographical or other formal errors, in
order that corrections may be made before the preliminary print goes to
press.

on writ of certiorari to the united states court of appeals for the
second circuit

[June 26, 1997]

Chief Justice Rehnquist
delivered the opinion of the Court.

In New York, as in most States, it is a crime to aid another to
commit or attempt suicide, [n.1]
but patients may refuse even lifesaving medical treatment. [n.2]
The question presented by this case is whether New York's prohibition on
assisting suicide therefore violates the Equal Protection Clause of the
Fourteenth
Amendment. We hold that it does not.

Petitioners are various New York public officials. Respondents
Timothy E. Quill, Samuel C. Klagsbrun, and Howard A. Grossman are physicians
who practice in New York. They assert that although it would be "consistent
with the standards of [their] medical practice[s]" to prescribe lethal
medication for "mentally competent, terminally ill patients" who are suffering
great pain and desire a doctor's help in taking their own lives, they are
deterred from doing so by New York's ban on assisting suicide. App. 25-26. [n.3]
Respondents, and three gravely ill patients who have since died, [n.4]
sued the State's Attorney General in the United States District Court.
They urged that because New York permits a competent person to refuse life
sustaining medical treatment, and because the refusal of such treatment
is "essentially the same thing" as physician assisted suicide, New York's
assisted suicide ban violates the Equal Protection Clause. Quill
v. Koppell, 870 F. Supp. 78, 84-85 (SDNY 1994).

The District Court disagreed: "[I]t is hardly unreasonable or
irrational for the State to recognize a difference between allowing nature
to take its course, even in the most severe situations, and intentionally
using an artificial death producing device." Id., at 84. The court
noted New York's "obvious legitimate interests in preserving life, and
in protecting vulnerable persons," and concluded that "[u]nder the United
States Constitution and the federal system it establishes, the resolution
of this issue is left to the normal democratic processes within the State."
Id., at 84-85.

The Court of Appeals for the Second Circuit reversed. 80 F. 3d 716 (1996).
The court determined that, despite the assisted suicide ban's apparent
general applicability, "New York law does not treat equally all competent
persons who are in the final stages of fatal illness and wish to hasten
their deaths," because "those in the final stages of terminal illness who
are on life support systems are allowed to hasten their deaths by directing
the removal of such systems; but those who are similarly situated, except
for the previous attachment of life sustaining equipment, are not allowed
to hasten death by self administering prescribed drugs." Id., at
727, 729. In the court's view, "[t]he ending of life by [the withdrawal
of life support systems] is nothing more nor less than assisted suicide."
Id., at 729 (emphasis added) (citation omitted). The Court of Appeals
then examined whether this supposed unequal treatment was rationally related
to any legitimate state interests, [n.5]
and concluded that "to the extent that [New York's statutes] prohibit a
physician from prescribing medications to be self administered by a mentally
competent, terminally ill person in the final stages of his terminal illness,
they are not rationally related to any legitimate state interest." Id.,
at 731. We granted certiorari, 518 U. S. ___ (1996), and now reverse.

The Equal Protection Clause commands that no State shall "deny to any
person within its jurisdiction the equal protection of the laws." This
provision creates no substantive rights. San Antonio Independent School
Dist. v. Rodriguez, 411
U.S. 1, 33 (1973); id., at 59 (Stewart, J., concurring). Instead,
it embodies a general rule that States must treat like cases alike but
may treat unlike cases accordingly. Plyler v. Doe, 457
U.S. 202, 216 (1982) (" `[T]he Constitution does not require things
which are different in fact or opinion to be treated in law as though they
were the same' ") (quoting Tigner v. Texas, 310
U.S. 141, 147 (1940)). If a legislative classification or distinction
"neither burdens a fundamental right nor targets a suspect class, we will
uphold [it] so long as it bears a rational relation to some legitimate
end." Romer v. Evans, 517 U. S. ___, ___ (slip op., at 10)
(1996).

New York's statutes outlawing assisting suicide affect and address
matters of profound significance to all New Yorkers alike. They neither
infringe fundamental rights nor involve suspect classifications. Washington
v. Glucksberg, ante, at 15-24; see 80 F. 3d, at 726; San
Antonio School Dist., 411 U. S., at 28 ("The system of alleged discrimination
and the class it defines have none of the traditional indicia of suspectness");
id., at 33-35 (courts must look to the Constitution, not the "importance"
of the asserted right, when deciding whether an asserted right is "fundamental").
These laws are therefore entitled to a "strong presumption of validity."
Heller v. Doe, 509
U.S. 312, 319 (1993).

On their faces, neither New York's ban on assisting suicide nor
its statutes permitting patients to refuse medical treatment treat anyone
differently than anyone else or draw any distinctions between persons.
Everyone, regardless of physical condition, is entitled, if competent,
to refuse unwanted lifesaving medical treatment; no one is permitted
to assist a suicide. Generally speaking, laws that apply evenhandedly to
all "unquestionably comply" with the Equal Protection Clause. New York
City Transit Authority v. Beazer, 440
U.S. 568, 587 (1979); see Personnel Administrator of Mass. v.
Feeney, 442
U.S. 256, 271-273 (1979) ("[M]any [laws] affect certain groups unevenly,
even though the law itself treats them no differently from all other members
of the class described by the law").

The Court of Appeals, however, concluded that some terminally
ill people--those who are on life support systems--are treated differently
than those who are not, in that the former may "hasten death" by ending
treatment, but the latter may not "hasten death" through physician assisted
suicide. 80 F. 3d, at 729. This conclusion depends on the submission that
ending or refusing lifesaving medical treatment "is nothing more nor less
than assisted suicide." Ibid. Unlike the Court of Appeals, we think
the distinction between assisting suicide and withdrawing life sustaining
treatment, a distinction widely recognized and endorsed in the medical
profession [n.6]
and in our legal traditions, is both important and logical; it is certainly
rational. See Feeney, supra, at 272 ("When the basic classification
is rationally based, uneven effects upon particular groups within a class
are ordinarily of no constitutional concern").

Furthermore, a physician who withdraws, or honors a patient's refusal
to begin, life sustaining medical treatment purposefully intends, or may
so intend, only to respect his patient's wishes and "to cease doing useless
and futile or degrading things to the patient when [the patient] no longer
stands to benefit from them." Assisted Suicide in the United States, Hearing
before the Subcommittee on the Constitution of the House Committee on the
Judiciary, 104th Cong., 2d Sess., 368 (1996) (testimony of Dr. Leon R.
Kass). The same is true when a doctor provides aggressive palliative care;
in some cases, painkilling drugs may hasten a patient's death, but the
physician's purpose and intent is, or maybe, only to ease his patient's
pain. A doctor who assists a suicide, however, "must, necessarily and indubitably,
intend primarily that the patient be made dead." Id., at 367. Similarly,
a patient who commits suicide with a doctor's aid necessarily has the specific
intent to end his or her own life, while a patient who refuses or discontinues
treatment might not. See, e.g., Matter of Conroy,supra,
at 351, 486 A. 2d, at 1224 (patients who refuse life sustaining treatment
"may not harbor a specific intent to die" and may instead "fervently wish
to live, but to do so free of unwanted medical technology, surgery, or
drugs"); Superintendent of Belchertown State School v. Saikewicz,
373 Mass. 728, 743, n. 11, 370 N. E. 2d 417, 426, n. 11 (1977) ("[I]n refusing
treatment the patient may not have the specific intent to die").

The law has long used actors' intent or purpose to distinguish between
two acts that may have the same result. See, e.g., United States
v. Bailey, 444
U.S. 394, 403-406 (1980) ("[T]he . . . common law of homicide often
distinguishes . . . between a person who knows that another person will
be killed as the result of his conduct and a person who acts with the specific
purpose of taking another's life"); Morissette v. United States,
342
U.S. 246, 250 (1952) (distinctions based on intent are "universal and
persistent in mature systems of law"); M. Hale, 1 Pleas of the Crown 412
(1847) ("If A., with an intent to prevent gangrene beginning in his hand
doth without any advice cut off his hand, by which he dies, he is not thereby
felo de se for tho it was a voluntary act, yet it was not with an
intent to kill himself"). Put differently, the law distinguishes actions
taken "because of" a given end from actions taken "in spite of" their unintended
but foreseen consequences. Feeney, 442 U. S., at 279; Compassion
in Dying v. Washington, 79 F. 3d 790, 858 (CA9 1996) (Kleinfeld,
J., dissenting) ("When General Eisenhower ordered American soldiers onto
the beaches of Normandy, he knew that he was sending many American soldiers
to certain death . . . . His purpose, though, was to . . . liberate Europe
from the Nazis").

Given these general principles, it is not surprising that many
courts, including New York courts, have carefully distinguished refusing
life sustaining treatment from suicide. See, e.g., Fosmire
v. Nicoleau, 75 N. Y. 2d 218, 227, and n. 2, 551 N. E. 2d 77, 82,
and n. 2 (1990) ("[M]erely declining medical . . . care is not considered
a suicidal act"). [n.7]
In fact, the first state court decision explicitly to authorize withdrawing
lifesaving treatment noted the "real distinction between the self infliction
of deadly harm and a self determination against artificial life support."
In re Quinlan, 70 N. J. 10, 43, 52, and n. 9, 355 A. 2d 647, 665,
670, and n. 9, cert. denied sub nom.Garger v. New Jersey,
429
U.S. 922 (1976). And recently, the Michigan Supreme Court also rejected
the argument that the distinction "between acts that artificially sustain
life and acts that artificially curtail life" is merely a "distinction
without constitutional significance--a meaningless exercise in semantic
gymnastics," insisting that "the Cruzan majority disagreed and so
do we." Kevorkian, 447 Mich., at 471, 527 N. W. 2d, at 728. [n.8]

Similarly, the overwhelming majority of state legislatures have drawn
a clear line between assisting suicide and withdrawing or permitting the
refusal of unwanted lifesaving medical treatment by prohibiting the former
and permitting the latter. Glucksberg, ante, at 4-6, 11-15.
And "nearly all states expressly disapprove of suicide and assisted suicide
either in statutes dealing with durable powers of attorney in health care
situations, or in `living will' statutes." Kevorkian, 447 Mich.,
at 478-479, and nn. 53-54, 527 N. W. 2d, at 731-732, and nn. 53-54. [n.9]
Thus, even as the States move to protect and promote patients' dignity
at the end of life, they remain opposed to physician assisted suicide.

New York is a case in point. The State enacted its current assisted
suicide statutes in 1965. [n.10]
Since then, New York has acted several times to protect patients' common
law right to refuse treatment. Act of Aug. 7, 1987, ch. 818, §1, 1987
N. Y. Laws 3140 ("Do Not Resuscitate Orders") (codified as amended at N.
Y. Pub. Health Law §§2960-2979 (McKinney 1994 and Supp. 1997));
Act of July 22, 1990, ch. 752, §2, 1990 N. Y. Laws 3547 ("Health Care
Agents and Proxies") (codified as amended at N. Y. Pub. Health Law §§2980-2994
(McKinney 1994 and Supp. 1997)). In so doing, however, the State has neither
endorsed a general right to "hasten death" nor approved physician assisted
suicide. Quite the opposite: The State has reaffirmed the line between
"killing" and "letting die." See N. Y. Pub. Health Law §2989(3) (McKinney
1994) ("This article is not intended to permit or promote suicide, assisted
suicide, or euthanasia"); New York State Task Force on Life and the Law,
Life Sustaining Treatment: Making Decisions and Appointing a Health Care
Agent 36-42 (July 1987); Do Not Resuscitate Orders: The Proposed Legislation
and Report of the New York State Task Force on Life and the Law 15 (Apr.
1986). More recently, the New York State Task Force on Life and the Law
studied assisted suicide and euthanasia and, in 1994, unanimously recommended
against legalization. When Death is Sought: Assisted Suicide and Euthanasia
in the Medical Context vii (1994). In the Task Force's view, "allowing
decisions to forego life sustaining treatment and allowing assisted suicide
or euthanasia have radically different consequences and meanings for public
policy." Id., at 146.

This Court has also recognized, at least implicitly, the distinction
between letting a patient die and making that patient die. In Cruzan
v. Director, Mo. Dept. of Health, 497
U.S. 261, 278 (1990), we concluded that "[t]he principle that a competent
person has a constitutionally protected liberty interest in refusing unwanted
medical treatment may be inferred from our prior decisions," and we assumed
the existence of such a right for purposes of that case, id., at
279. But our assumption of a right to refuse treatment was grounded not,
as the Court of Appeals supposed, on the proposition that patients have
a general and abstract "right to hasten death," 80 F. 3d, at 727-728, but
on well established, traditional rights to bodily integrity and freedom
from unwanted touching, Cruzan, 497 U. S., at 278-279; id.,
at 287-288 (O'Connor, J., concurring). In fact, we observed that "the majority
of States in this country have laws imposing criminal penalties on one
who assists another to commit suicide." Id., at 280. Cruzan
therefore provides no support for the notion that refusing life sustaining
medical treatment is "nothing more nor less than suicide."

For all these reasons, we disagree with respondents' claim that the
distinction between refusing lifesaving medical treatment and assisted
suicide is "arbitrary" and "irrational." Brief for Respondents 44. [n.11]
Granted, in some cases, the line between the two may not be clear, but
certainty is not required, even were it possible. [n.12]
Logic and contemporary practice support New York's judgment that the two
acts are different, and New York may therefore, consistent with the Constitution,
treat them differently. By permitting everyone to refuse unwanted medical
treatment while prohibiting anyone from assisting a suicide, New York law
follows a longstanding and rational distinction.

New York's reasons for recognizing and acting on this distinction--including
prohibiting intentional killing and preserving life; preventing suicide;
maintaining physicians' role as their patients' healers; protecting vulnerable
people from indifference, prejudice, and psychological and financial pressure
to end their lives; and avoiding a possible slide towards euthanasia--are
discussed in greater detail in our opinion in Glucksberg, ante.
These valid and important public interests easily satisfy the constitutional
requirement that a legislative classification bear a rational relation
to some legitimate end. [n.13]

The judgment of the Court of Appeals is reversed.

It is so ordered.

Notes

1 N.
Y. Penal Law §125.15 (McKinney 1987) ("Manslaughter in the second
degree") provides: "A person is guilty of manslaughter in the second degree
when . . . (3) He intentionally causes or aids another person to commit
suicide. Manslaughter in the second degree is a class C felony." Section
120.30 ("Promoting a suicide attempt") states: "A person is guilty of promoting
a suicide attempt when he intentionally causes or aids another person to
attempt suicide. Promoting a suicide attempt is a class E felony." See
generally, Washington v. Glucksberg, ___ U. S. ___ (1997),
ante, at 4-15.

2 "It
is established under New York law that a competent person may refuse medical
treatment, even if the withdrawal of such treatment will result in death."
Quill v. Koppell, 870 F. Supp. 78, 84 (SDNY 1994); see N.
Y. Pub. Health Law, Art. 29-B, §§2960-2979 (McKinney 1993 &
Supp. 1997) ("Orders Not to Resuscitate") (regulating right of "adult with
capacity" to direct issuance of orders not to resuscitate); id.,
§§2980-2994 ("Health Care Agents and Proxies") (allowing appointment
of agents "to make . . . health care decisions on the principal's behalf,"
including decisions to refuse lifesaving treatment).

4 These
three patients stated that they had no chance of recovery, faced the "prospect
of progressive loss of bodily function and integrity and increasing pain
and suffering," and desired medical assistance in ending their lives. App.
25-26; Declaration of William A. Barth, id., at 96-98; Declaration
of George A. Kingsley, id., at 99-102; Declaration of Jane Doe,
id., at 105-109.

5 The
court acknowledged that because New York's assisted suicide statutes "do
not impinge on any fundamental rights [or] involve suspect classifications,"
they were subject only to rational basis judicial scrutiny. 80 F. 3d, at
726-727.

6 The
American Medical Association emphasizes the "fundamental difference between
refusing life sustaining treatment and demanding a life ending treatment."
American Medical Association, Council on Ethical and Judicial Affairs,
Physician Assisted Suicide, 10 Issues in Law & Medicine 91, 93 (1994);
see also American Medical Association, Council on Ethical and Judicial
Affairs, Decisions Near the End of Life, 267 JAMA 2229, 2230-2231, 2233
(1992) ("The withdrawing or withholding of life sustaining treatment is
not inherently contrary to the principles of beneficence and nonmaleficence,"
but assisted suicide "is contrary to the prohibition against using the
tools of medicine to cause a patient's death"); New York State Task Force
on Life and the Law, When Death is Sought: Assisted Suicide and Euthanasia
in the Medical Context 108 (1994) ("[Professional organizations] consistently
distinguish assisted suicide and euthanasia from the withdrawing or withholding
of treatment, and from the provision of palliative treatments or other
medical care that risk fatal side effects"); Brief for the American Medical
Association et al. as Amici Curiae 18-25. Of course, as respondents'
lawsuit demonstrates, there are differences of opinion within the medical
profession on this question. See New York Task Force, When Death is Sought,
supra, at 104-109.

7 Thus,
the Second Circuit erred in reading New York law as creating a "right to
hasten death"; instead, the authorities cited by the court recognize a
right to refuse treatment, and nowhere equate the exercise of this right
with suicide. Schloendorff v. Society of New York Hospital,
211 N. Y. 125, 129-130, 105 N. E. 92, 93 (1914), which contains Justice
Cardozo's famous statement that "[e]very human being of adult years and
sound mind has a right to determine what shall be done with his own body,"
was simply an informed consent case. See also Rivers v. Katz,
67 N. Y. 2d 485, 495, 495 N. E. 2d 337, 343 (1986) (right to refuse antipsychotic
medication is not absolute, and may be limited when "the patient presents
a danger to himself"); Matter of Storar, 52 N. Y. 2d 363, 377, n.
6, 420 N. E. 2d 64, 71, n. 6, cert. denied, 454
U.S. 858 (1981).

10 It
has always been a crime, either by statute or under the common law, to
assist a suicide in New York. See Marzen, O'Dowd, Crone, & Balch, Suicide:
A Constitutional Right?, 24 Duquesne L. Rev. 1, 205-210 (1985) (Appendix).

11 Respondents
also argue that the State irrationally distinguishes between physician
assisted suicide and "terminal sedation," a process respondents characterize
as "induc[ing] barbiturate coma and then starv[ing] the person to death."
Brief for Respondents 48-50; see 80 F. 3d, at 729. Petitioners insist,
however, that " `[a]lthough proponents of physician assisted suicide and
euthanasia contend that terminal sedation is covert physician assisted
suicide or euthanasia, the concept of sedating pharmacotherapy is based
on informed consent and the principle of double effect.' " Reply Brief
for Petitioners 12 (quoting P. Rousseau, Terminal Sedation in the Care
of Dying Patients, 156 Archives Internal Med. 1785, 1785-1786 (1996)).
Just as a State may prohibit assisting suicide while permitting patients
to refuse unwanted lifesaving treatment, it may permit palliative care
related to that refusal, which may have the foreseen but unintended "double
effect" of hastening the patient's death. See New York Task Force, When
Death is Sought, supra, n. 6, at 163 ("It is widely recognized that
the provision of pain medication is ethically and professionally acceptable
even when the treatment may hasten the patient's death, if the medication
is intended to alleviate pain and severe discomfort, not to cause death").

12 We
do not insist, as Justice Stevens suggests, ante, at 14-15 (concurring
opinion), that "in all cases there will in fact be a significant difference
between the intent of the physicians, the patients or the families [in
withdrawal of treatment and physician assisted suicide cases]." See 6-7,
supra ("[A] physician who withdraws, or honors a patient's refusal
to begin, life sustaining medical treatment purposefully intends, or
may so intend, only to respect his patient's wishes . . . . The same
is true when a doctor provides aggressive palliative care; . . . the physician's
purpose and intent is, or may be, only to ease his patient's pain")
(emphasis added). In the absence of omniscience, however, the State is
entitled to act on the reasonableness of the distinction.

13 Justice
Stevens observes that our holding today "does not foreclose the possibility
that some applications of the New York statute may impose an intolerable
intrusion on the patient's freedom." Ante, at 16 (concurring opinion).
This is true, but, as we observe in Glucksberg, ante, at
31-32, n. 24, a particular plaintiff hoping to show that New York's assisted
suicide ban was unconstitutional in his particular case would need to present
different and considerably stronger arguments than those advanced by respondents
here.